Surgery Under Regional Anesthesia
Jean Daniel Eloy, MD
Assistant Professor
Residency Program Director
Rutgers-New Jersey Medical School
Rutgers The State University of New Jersey
Regional Anesthesia
• Peripheral Nerve Block
• 1) Some decrease in Stress Response
• 2) Decrease in Tumor Recurrence ( Mastectomy)
• 3) Better Glucose Control
• 4) Reduced Opiates Used and Requirement
Principles Of Solography
• Frequency of medical US: 2MHz –13MHz
• Structures >1mm
• Nerves are 2mm-10mm
Quality and Resolution of US
• High frequency probes: Better Images Resolution
• Fat: Low resolution
• Angle of Incidence
• Gain=Brightness
Brachial Plexus Anatomy
ANATOMY
• The Brachial Plexus is made up of anterior primary rami of C5, C6,
C7, C8 and T1 with variable contributions from C4 and T2
• After leaving their intervertebral foramina these nerves course
between the anterior and middle scalene muscles
• Between the scalene muscles the nerves unite to form three trunks.
The superior (C5, C6,), middle (C7) and inferior (C8 and T1)
Anatomy of the Brachial Plexus
Interscalenene Nerve Block
• Principal indication for interscalene block is shoulder
surgery
• This block is not performed for forearm and hand surgery
because the inferior trunk (C8—T1) is often incomplete
• Ultrasound guided block technique
Ultrasound Guided Brachial Plexus Block
Ultrasound Guided Brachial Plexus Block
COMPLICATIONS OF INTERSCALENE BLOCKS
• Ipsilateral phrenic nerve resulting in diaphragmatic paresis
occurs in 100% of patients undergoing interscalene blockade
•
a)This results in 25% reduction in
pulmonary function
b)The phrenic nerve is blocked because of its location
overlying the anterior scalene muscle
COMPLICATIONS OF INTERSCALENE
BLOCKS
• A cervical sympathetic block occurs frequently :
(Horner’s syndrome)
a) miosis
b) anhydrosis
c) ptosis
d) vasodilation
• Recurrent laryngeal nerve block can occur resulting in
hoarseness
SUPRACLAVICULAR BLOCKS
• Is used for upper extremity surgery distal to
the level of the shoulder
• Is done at level of the trunks dividing into
divisions
• Has the fastest onset of all brachial plexus
blocks because of its compact volume a
this location
• The incidence of pneumothorax with
classical block technique was .5 to 6%
SUPRACLAVICULAR BLOCKS
• Using a 22 G needle symptoms is usually
delayed. May take up to 24 hrs.
• Chest x-ray is not justified
• Phrenic nerve block occurs 40 to 60% of
the time
• Horner’s syndrome is common
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Supraclavicular Nerve Block
Infraclavicular Nerve Block
• Provides anesthesia for any procedure below the level of
shoulder
• Blockade occurs at the level of the cords
• Offers the theoretical advantage of avoiding
pneumothorax while blocking the musculocutaneous
when it is still in the plexus
• Technique for performing block:
a) nerve stimulator
b) ultrasound guided
• Complications are rare
INFRACLAVICULAR BLOCK
INFRACLAVICULAR BLOCK
Axillary Nerve Block
• Axillary can be used for any surgery distal to the elbow
• The block occurs at the level of the terminal nerves
• Techniques for axillary block
a) trans arterial technique
b) nerve stimulator technique
c) ultrasound
• The musculocutaneous nerve is not in the axillary sheath and must
be blocked separately
a) it innervates biceps and coracobrachialis muscle
b) below the level of the elbow it innervates the skin on the lateral
part of the forearm down to the base of the thumb
Axillary Nerve Block
c) the musculocutaneous nerve lies in the body of the
coracobrachialis muscle which is deep and lateral to the
axillary artery
d) the intercostobrachial nerve is often blocked at this
level by injecting a subcutaneous wheal of local
anesthetic 2 cm above and below the axillary artery
• Complications are rare
Nerve Anatomy
Axillary Block
AXILLARY BLOCK
ANATOMY LOWER EXTREMITY BLOCKS
•
•
•
•
•
The nerve supply to the lower extremity is derived from
the lumbar and sacral plexuses
The lumbar plexus is formed by the anterior rami of
first four lumbar nerves and variable contributions from
T12 and L5.
The plexus lies between the psoas major and
quadratus lumborum muscles in what is called the
psoas compartment
The lumbar plexus gives rise to the lateral femoral
cutaneous, femoral and obdurate nerves
The sacral plexus is derived from the first, second, and
third sacral nerves and the anterior rami of L4 and L5
ANATOMY LOWER EXTREMITY BLOCKS
(cont.)
•
•
The sacral plexus gives rise to the posterior
cutaneous nerve of the thigh and the sciatic
nerve
The sciatic nerve passes down through the
pelvis and greater sciatic foramen. It travels
down the back k of the thigh to the popliteal
fossa where it separates into the tibia and
common peronei nerves
PSOAS COMPARTMENT BLOCK
• Psoas compartment used for postoperative analgesia for
patients undergoing major knee and hip surgery
• Offers a simple injection technique for blocking femoral,
obdurate and lateral femoral cutaneous nerves
• Techniques:
a) locate L4 by drawing a line that connects the iliac
crest
b) 10 cm insulated needle is inserted 4 cm lateral to
the midline of spinouts process for L4 on the side to be
blocked
PSOAS COMPARTMENT BLOCK (cont.)
c) Insert the needle perpendicular to the skin until a
quadriceps response is obtained
e) Inject 30ml of local anesthetic
• Complications:
a) epidural injection or spread
b) Subarachnoid
c) vascular injection
PSOAS COMPARTMENT BLOCK
PSOAS COMPARTMENT BLOCK
PSOAS COMPARTMENT BLOCK
PSOAS COMPARTMENT BLOCK
PSOAS COMPARTMENT BLOCK
ANTERIOR PSOAS COMPARTMENT
BLOCK
•
Assumes that the facial sheath that surrounds the lumbar
roots extends into the femoral canal and acts as an
enclosed conduit for the spread of local anesthetic.
•
Work in the minority of cases even when large volumes of
local anesthetic are used
•
Reliable and provides anesthesia for the femoral and
lateral femoral cutaneous nerves
Fascia Iliaca Block
FEMORAL NERVE BLOCKS
• Used for postoperative analgesia for knee
surgery
• Technique :
a) ultrasound stimulator
b) nerve stimulator
1) lateral to medial
nerve to artery to vein
2) insert insulated needle 1 cm lateral to
femoral artery
FEMORAL NERVE BLOCKS
Look for patellar movement to make sure the
main part of the femoral nerve is being
stimulated
• Complications are usually rare
• The terminal branch of femoral nerve
becomes the saphenous nerve
FEMORAL NERVE BLOCKS
FEMORAL NERVE BLOCKS
SCIATIC NERVE BLOCK
•
•
•
Can be used for any surgery below the knee when combined with
a saphenous nerve block
Technique:
a) Ultrasound
b) Nerve Stimulator
1) Lateral position, with leg to be blocked rolled forward onto
the flex knee as the heel rests on the dependent knee
2) A line is drawn to connect the posterior superior iliac spine
to the greater trochanter
3) A perpendicular line is drawn bisecting this line and
extending caudad
4) A second line is drawn from the greater trochanter to the
sacral hiatus
5) Where the bisecting intersects this second line is the point
of needle entry
Complications--Rare
SCIATIC NERVE BLOCK
SCIATIC NERVE BLOCK
SCIATIC NERVE BLOCK
SCIATIC NERVE BLOCK
SCIATIC NERVE BLOCK
SCIATIC NERVE BLOCK
POPLITEAL FOSSA BLOCK
• Clinical application-foot and ankle surgery when
combined with saphenous nerve block
• This is a sciatic nerve block in the proximal part
of the popliteal fossa before it divides into the
tibia and common peronei nerves
• Techniques:
a) Ultrasound
b) Nerve Stimulator
1) Outline the borders of the popliteal fossa
POPLITEAL FOSSA BLOCK
medial border- semimembranosus and
semitendinosus
lateral border- biceps femoris
caudad border- crease formed by
gastrocnemius muscles
2) Draw a line bisecting the fossa from the apex
to the base
3) Mark a point at least 7 cm proximal to the
base
POPLITEAL FOSSA BLOCK
4) Mark an injection point 1 cm lateral to this
point
5) Insert stimulating needle (plantar flexion, tibia
nerve stimulation provides more reliable block)
• Complications- Rare
POPLITEAL FOSSA BLOCK
POPLITEAL FOSSA BLOCK
POPLITEAL FOSSA BLOCK
ANKLE BLOCKS
• Provides surgical anesthesia to the foot not
requiring a tourniquet
• Four of five nerves are terminal branches of the
sciatic nerve. The saphenous nerve is the
terminal branch of the femoral nerve
• Ankle block consists of two deep nerves below
superficial facial (posterior tibia and deep
peronei) and three superficial nerve above the
superficial facial (surah, saphenous and
superficial peronei)
ANKLE BLOCKS
ANKLE BLOCKS
• Deep blocks can be performed with ultrasound guidance
• Deep peronei nerve:
a) Provides anesthesia between the first and second toes
b) it is located between the extensor halluces long us and the
exterior digit rum long us
ANKLE BLOCKS
ANKLE BLOCKS
ANKLE BLOCKS
ANKLE BLOCKS
ANKLE BLOCKS
PARAVERTEBRAL BLOCK
• Clinical applications: post-thoracotomy and post-mastectomy
pain
• Paravertebral blockade occurs as the spinal nerves emerge
from the vertebral foramina.
• This results in somatic and sympathetic block of multiple
contiguous thoracic dermatomes above and below the
injection site
PARAVERTEBRAL BLOCK
• Techniques:
a) Thoracic region
1) the spinouts processes are identified
2) a needle is inserted 2.5 to 3 cm lateral to the most
cephalic aspect of the spinouts process and advanced
perpendicular to the skin
3) the vertebral transverse process of the level below is
contacted at 2 to 4 cm
PARAVERTEBRAL BLOCK
4) The transverse process is walked off in a cephalic
direction and advanced until a loss of resistance is
obtained (about 1 to 1.5 cm)
5) 15 ml of local results four or five dermatomes spread
b) Lumbar region;
1) Lines drawn across the cephalic edge of the spinouts
processes
PARAVERTEBRAL BLOCK
2) 3 cm lateral along these lines a needle is advances
perpendicular to the skin until the homologous transverse
processes are contacted (about 3 to 5 cm)
3) Walk off the caudal edge of the transverse processes and
insert needle and additional 1 to 2 cm
4) 6 to 10 ml of local in injected
5) Complications—Epidural or subarachnoid injections,
intravascular injections, plural puncture, pneumothorax
PARAVERTEBRAL BLOCK
PARAVERTEBRAL BLOCK
PARAVERTEBRAL BLOCK
PARAVERTEBRAL BLOCK
Transverses Abdominals Plan Block
• Regional anesthetic technique used to block sensation to the
anterior abdominal wall.
•
• Provides anesthesia and analgesia coverage from T9 to T11
dermatomes
• Great for Appendectomies, ventral and inguinal hernia repairs
as well as open gastrostomy tube insertion.
Transverses Abdominals Plan Block